Onur Sildiroglu

Performance of the probe-to-bone test in a population suspected of having osteomyelitis of the foot in diabetes.

BACKGROUND We investigated the validity of probe-to-bone testing in the diagnosis of osteomyelitis in a selected subgroup of patients clinically suspected of having diabetic foot osteomyelitis. METHODS Between January 1, 2007, and December 31, 2008, inpatients and outpatients with a diabetic foot ulcer were prospectively evaluated, and those having a clinical diagnosis of foot infection and at least one of the osteomyelitis clinical suspicion criteria were consecutively included in this study. RESULTS Sixty-five patients met the inclusion criteria and were prospectively enrolled in the study. Forty-nine patients (75.4%) were hospitalized, and the remaining 16 (24.6%) were followed as outpatients. Osteomyelitis was diagnosed in 39 patients (60.0%). Probe-to-bone test results were positive in 30 patients (46.1%). The positive predictive value for the probe-to-bone test was fairly high (87%), but the negative predictive value was only 62%. The sensitivity and specificity of the test were 66% and 84%, respectively. White blood cell counts and mean C-reactive protein levels did not statistically significantly differ between groups. However, erythrocyte sedimentation rates greater than 70 mm/h reached statistical significance between groups. Wound area and depth were not found to be statistically significantly different between groups. CONCLUSIONS Positive probe-to-bone test results and erythrocyte sedimentation rates greater than 70 mm/h provide some support for the diagnosis of diabetic foot osteomyelitis, but it is not strong; magnetic resonance imaging or bone biopsy will probably be required in cases of doubt.

Can procalcitonin predict bone infection in people with diabetes with infected foot ulcers? A pilot study

AIMS The diagnosis of osteomyelitis is a key step of diabetic foot management. Previous studies showed that procalcitonin (PCT), a novel infection marker, is superior to conventional infection markers in the diagnosis of diabetic foot infection. This study aimed to investigate the serum levels of PCT and other conventional infection markers in diabetic persons with and without osteomyelitis. METHODS Twenty-four patients (18 male, mean age: 61.9±10.8 years) with infected foot ulcers were prospectively enrolled. Clinical characteristics of the wounds were noted. Blood samples were obtained for biochemical analysis. Magnetic resonance imaging of the foot was performed in all patients to diagnose osteomyelitis. RESULTS Osteomyelitis was found in 13 of 24 (54%) patients. PCT levels were 66.7±43.5 pg/ml in patients with osteomyelitis and 58.6±35.5 pg/ml in patients without osteomyelitis. The difference did not reach statistical significance (p=0.627). Erythrocyte sedimentation rate, but not C-reactive protein and white blood cell count, was found significantly higher in patients with osteomyelitis. CONCLUSION In this group of patients, PCT failed to discriminate patients with bone infection. Erythrocyte sedimentation rate can be used as a marker of osteomyelitis in diabetic persons.

Evaluation of cochlear nerve size by magnetic resonance imaging in elderly patients with sensorineural hearing loss

PurposeWe aimed to determine any differences, if present, between the cross-sectional area of the cochlear nerve (CN) of elderly patients with sensorineural hearing loss (SNHL) and of young patients with normal hearing.Materials and methodsThe study group included ten patients with age-related SNHL. Fourteen volunteer individuals with normal hearing were recruited as the control group. T1-weighted, T2-weighted and parasagittal three-dimensional Fourier transformation constructive interference in steady state (3DFT-CISS) reconstruction images of all cases were evaluated. Images were examined for any abnormality of CN. The data obtained for each ear with clinical, radiological and audiometric examinations were evaluated.ResultsThe mean CN cross-sectional area was measured as 0.0252 cm2 in the control group, whereas that in the SNHL group was 0.0232 cm2. Although speech discrimination scores showed significant differences, no statistically significant difference was observed for the CN cross-sectional area (p=0.0616). Likewise, there was no difference in CN calibre between male and female patients.ConclusionsThe 3DFT-CISS sequence yields superior results in CN imaging. Acquired SNHL may not present with significant changes in CN size on magnetic resonance imaging (MRI).RiassuntoObiettivoDeterminare se esistono differenze, in misure effettuate su sezioni trasversali di immagini di risonanza magnetica, tra l’area del nervo cocleare (CN) in pazienti anziani con perdita dell’udito di tipo neurosensoriale (SNHL) e soggetti giovani con udito normale.Materiali e metodiIl gruppo di studio comprende 10 pazienti con perdita dell’udito di tipo neurosensoriale. Sono stati reclutati, come gruppo di controllo 14 volontari con udito normale. Sono state effettuate acquisizioni T1 e T2 dipendenti e tridimensionali in steady state (3DFTCISS). Le immagini sono state valutate per la ricerca di qualsiasi anormalità del nervo cocleare. Sono stati valutati per ogni caso i dati clinici, radiologici e audiometrici.RisultatiL’area sulla sezione trasversale del CN nel gruppo di pazienti con SNHL era pari a 0,0232 cm2 mentre nel gruppo di controllo era pari a 0,0252 cm2. Sebbene i punteggi di discriminazione del linguaggio mostrassero differenze significative, non è stata evidenziata nessuna differenza statisticamente significativa per l’area trasversale del CN (p=0,0616). Altrettanto, non vi era alcuna differenza del calibro del CN tra soggetti di sesso maschile e femminile.ConclusioniLa sequenza 3DFT-CISS ottiene risultati superiori nella visualizzazione del CN. La SNHL acquisita può non presentare cambiamenti significativi delle dimensioni del CN alla risonanza magnetica.

A magnetic resonance spectroscopy study of antisocial behaviour disorder, psychopathy and violent crime among military conscripts

Background: Prefrontal and/or temporo-limbic abnormalities associated with antisocial personality disorder (APD), high psychopathy scores and violent behaviours can readily be evaluated by neuroimaging methods. Objectives: In this study, we compared the brain metabolites in adult male military conscripts with APD, high psychopathy scores and serious violent crimes (n = 15) with age- and educational-level-matched healthy controls (n = 15) by means of magnetic resonance spectroscopy. Methods: All cases were diagnosed by means of the Diagnostic Statistical Manual-IV APD module of the Structured Clinical Interview for DSM III-R Axis II Disorders (SCID-II) semistructured questionnaire in Turkish. The psychopathy scores were evaluated by means of the Hare Psychopathy Checklist-Revised translated into Turkish (PCL-R). PCL-R is a 20-item, reliable and valid instrument for assessment of psychopathy, both in categorical and dimensional natures. All patients had a total score of 29 (of possible 40) or higher from PCL-R, indicating a high degree of psychopathy. Results: Our results showed no significant differences in ratio of N-acetyl aspartate (NAA), creatine (Cr) and choline-related compounds in the right dorsolateral prefrontal cortex, anterior cingulate cortex (ACC) and amygdala–hippocampus regions of cases compared with controls. ACC NAA/Cr was significantly negatively correlated with both the PCL-R total score and the PCL-R factor I score (interpersonal/affective problems) among the cases. Conclusion: As ACC plays an important role in decision-making and emotional information processing, we postulate that the lower NAA/Cr ratio, suggesting impaired neural integrity, may increase the severity of interpersonal/affective problems of the psychopathy factor in male subjects exhibiting APD, high psychopathy overall scores and violent crimes.

Abnormal aortic elasticity in patients with liver steatosis

AIM Non-alcoholic fatty liver disease (NAFLD) may be associated with insulin resistance. We aimed to evaluate elastic properties of aorta in patients with NAFLD. MATERIAL AND METHOD Ninety-two patients with NAFLD and 47 healthy subjects were performed ultrasonographic and echocardiographic examination. Aortic stiffness index (ASI), aortic distensibility (AD) and aortic strain (AS) were compared between healthy subjects and patients and also among grade I and II liver steatosis. Statistical analysis was performed by Independent-Samples t-test, Pearsons correlation test using SPSS 11.0. RESULTS ASI was significantly increased whereas AS and AD were reduced (p>0.05) in patients compared to normal ones. ASI was significantly increased while AD and AS slightly increased in patients with grade II liver steatosis compare to grade I. SBP and DBP, cholesterol levels, fasting blood glucose (FBG) were also increased and doppler flow parameters of mitral inflow were abnormally changed in those patients. ASI was positively correlated with FBG, ALT and ALP levels, LDL cholesterol, heart rate and deceleration time of mitral E wave. CONCLUSION Elastic properties of aorta were abnormally changed in patients with NAFLD. Multiple hemodynamic abnormalities probably associated with insulin resistance may be accountable for abnormal elastic properties of aorta.

Hepatobiliary and pancreatic: Solid pseudopapillary tumor of the pancreas

A 42-year-old woman was investigated because of epigastric discomfort and mid-abdominal distension after meals. A non-contrast computed tomography (CT) scan of the abdomen revealed a somewhat heterogeneous mass, 10 ¥ 9 cm in size, in the head of the pancreas (Fig. 1). There was patchy calcification at the periphery of the mass. With a contrast-enhanced CT scan, the mass had well-defined margins and a poorly perfused central area consistent with either necrosis or cystic change (Fig. 2). The patient was treated surgically by pancreaticoduodenectomy with apparent complete removal of the mass. Histological evaluation revealed a solid pseudopapillary tumor of the pancreas. Solid pseudopapillary tumors of the pancreas are rare indolent neoplasms that largely affect young women. The female to male ratio has been reported as 10:1 with a mean age at diagnosis of approximately 25 years. Symptoms are usually non-specific but include abdominal pain, abdominal distension and the presence of a palpable mass. At diagnosis, most tumors are relatively large with a mean diameter in one study of greater than 10 cm. Macroscopically, typical neoplasms have both solid and cystic components with the latter feature attributed to necrosis, degeneration or hemorrhage. Histologically, solid areas have patternless sheets of epithelial cells associated with a rich microvasculature. In cystic areas, degenerative changes create a pseudopapillary pattern where residual cells form perivascular rosettes. In contrast to ductal adenocarcinomas of the pancreas, solid pseudopapillary neoplasms do not have mutations in K-ras or p53. However, approximately 90% have activating mutations in the b-catenin oncogene with nuclear accumulation of b-catenin protein. Surgical resection is the major form of therapy with pancreaticoduodenectomy for lesions in the head of the pancreas and distal pancreatectomy for lesions in the body or tail. Metastases can occur in up to 20% of patients but should not necessarily be a contraindication to aggressive surgical resection. In patients deemed unresectable, case reports indicate some success with radiotherapy and chemotherapy. Five-year survival rates have been reported as 95% with some longer-term survival even in the presence of metastatic disease.

Gastrointestinal: Diffuse large B‐cell lymphoma of the small bowel

A woman, aged 65 years, was investigated because of the recent onset of abdominal pain. A computed tomography (CT) scan of the abdomen revealed a mass, approximately 6 × 8 cm in size, in the left mid-abdomen (Fig. 1). Although the center of the mass was somewhat heterogeneous, the margins were well-defined and there was no apparent stranding or inflammation of the surrounding fat tissue. The proximal small bowel was moderately dilated. At laparotomy, she had a large mass in the upper jejunum that was removed by segmental resection. Histological evaluation revealed a diffuse large B-cell lymphoma. Six months after surgery she developed obstructive jaundice. Magnetic resonance cholangiopancreatography revealed dilatation of the bile duct apparently caused by obstruction in the region of the ampulla. A repeat CT scan showed marked thickening of the wall of the second part of the duodenum (long arrow) and a dilated bile duct (short arrows). Duodenal endoscopy was abnormal and biopsies confirmed the presence of large B-cell lymphoma. She was treated by chemotherapy. Diffuse large B-cell lymphomas account for 50–66% of extranodal lymphomas in the gastrointestinal tract. The most common sites are the stomach and the ileocecal region. Although most of these neoplasms are primary, a minority may progress from less aggressive lymphomas such as MALT lymphomas or follicular lymphomas. Therapeutic options include surgery, chemotherapy and radiotherapy. Surgery is indicated in those who present with bowel obstruction and is sometimes necessary in order to obtain tissue for diagnosis. Patients with localized (stage 1 or 2) large B-cell lymphoma can be treated initially with either surgery or radiotherapy. Those with more advanced disease are best treated by chemotherapy. The prognosis varies widely and is dependent on tumor stage, lactate dehydrogenase concentrations, performance status and age.